Multidimensional Caregiving Burden of Female Family Caregivers in Korea.

591472 research-article2015

CNRXXX10.1177/1054773815591472Clinical Nursing ResearchLim et al.

Article

Multidimensional Caregiving Burden of Female Family Caregivers in Korea

Clinical Nursing Research 1–18 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773815591472 cnr.sagepub.com

Young Mi Lim, PhD, RN1, Yang Heui Ahn, PhD, RN, HCN-APN1, and Ji Yeong Ahn, MSN, RN1

Abstract The purpose of this study was to examine a staged theoretical model to explain cultural knowledge-based multidimensional burden of women family caregivers caring for community-dwelling older adults using a modified Poulshock and Deimling model. In the model, the antecedents included elders’ impairment in activities of daily living (ADL), elders’ cognitive impairment, caregivers’ self-efficacy, and caregivers’ familism. The perception contained the disruptive behavior burden and social functioning burden of caregivers. The consequence variable included social activity restriction and negative changes in family relationships. The total sample was 157 primary women caregivers caring for community-dwelling older adults aged 65 and older. Instruments were General Self-Efficacy Scale, Family Scale, and Burden Scale. Path analysis was done to analyze the model using multiple linear regression methods. This study showed that impairments of older adults (impairment in ADL, cognitive impairment) and caregiver beliefs (strong familism, low self-efficacy) had an indirect influence on negative changes in family relationship and social activity restriction through the perceived emotional distress.

1Yonsei

University, Wonju College of Medicine, Korea

Corresponding Author: Yang Heui Ahn, Professor, Yonsei University , Wonju College of Medicine, Department of Nursing, Ilsan-ro 20, Gangwon-do, Wonju 220-701, Korea. Email: [email protected]

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Clinical Nursing Research

Keywords family caregiver, burden, familism, self-efficacy

Significance In Korea, one out of every eight people is over the age of 65, and this age group represented 12.2% of the population in 2013 (Statistics Korea, 2013). This number is expected to swell to 24.3% by 2030. Statistics Korea (2013) found that the older adult population is increasing faster than any of the younger populations. The implication of these trends is that the number of older adults with chronic disease is expected to increase. More than 86% of elders have been diagnosed with at least one chronic disease, nearly 23% have one or more limitations in instrumental activities of daily living (IADL) and more than 8% have limitations with basic activities of daily living (ADL; Cho, Cho, & Kim, 2010). Family members, the majority of which are daughters or daughters-in-law, provide care to frail older adults with chronic diseases at home (E. E. Lee & Farran, 2004; M. H. Lee, Yoon, & Kropf, 2007). Family caregiving of elders at home is influenced by the cultural norms of respect for age and filial piety, derived from Korean Confucian value (Kong, 2007; Sung, 2001). This fact underscores the importance of the role of the family in care of the older adults rather than the need for long-term care. The role of the family, however, is diminishing due to recent changes in family structure and participation of women in the labor force (Jang, Avendano, & Kawachi, 2012). These changes are directly related to the problems, including caregiving strain experienced by female caregivers (J. S. Kim, 2001). Consequently, care for impaired older adults is becoming an urgent social issue. Despite recent increases in long-term care services, many older Korean adults are still living at home and dependent on their families (M. H. Lee et al., 2007). Until recently, approximately three fourths of the frail older adult care was provided by family caregivers in the home (Korean Statistical Information Service, 2012). Yet existing support programs for family caregivers are very limited (S. Kim & Woo, 2013). As a result, family caregivers often suffer from the burden of caregiving. Family caregiving burden has emerged as an important concept for determining the impact of quality of family caregiving on frail older adults (Schulz & Martire, 2004). Defining and measuring caregiving burden are complex and invoke great controversy. Some studies reported that burden refers to emotional response to changes and demands that occur as they give help and support to care recipients (Zarit, Reever, & Bach-Peterson, 1980; Zarit, Todd, & Zarit, 1986), while some studies reported that the concept of burden is


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regarded as both objective and subjective dimensions (Montgomery, Gonyea, & Hooyman, 1985; Platt, 1985). Poulshock and Deimling (1984) made a major contribution to resolving these difficulties by proposing a narrower definition of burden and examining the multidimensional perspective of caregiver burden. In Poulshock and Deimling’s study of 614 families living with and caring for an impaired older adult, they identified the relationship of burden to impairment level of the recipient and the effects of this burden on the relationship between caregivers and care recipients. Their research indicates that reported burden correlates with the frail elder’s impairment in cognitive functioning, in everyday behaviors such as sociability, and in ADL. These factors affect the quality of the relationship between the caregiver and the frail older adults and lead to more or less interpersonal conflict, as well as restriction of activities for caregivers. In this study, the caregiving burden model conceptualized by Poulshock and Deimling (1984) was chosen because of its conceptual clarity and specificity across cultures. Poulshock and Deimling proposed a model of caregiving burden that caregiver perceived as a result of attending to various impairments of older adults, and focused on caregiving impact on the lives of family caregivers. The model assumed that burden was regarded as three stages, in which thoughts or beliefs affect negative emotional responses resulting in impact behaviors. In many studies across cultures, cognitive impairment and difficulty with ADL of older adults influenced on caregiving resulting in negative relationships (Bang & Jang, 2007; Papastavrou, Kalokerinou, Papacostas, Tsangari, & Sourtzi, 2007; Singh & Cameron, 2005; Zhang, Xiong, Hujiken, Zhang, & Zhang, 2013). In addition, in the majority of studies conducted throughout the world, a high correlation was found between caregiver burden and caregiving impact (Peter, 2014; Quinn, Clare, McGuinness, & Woods, 2012; Sohn, 2011). It is posited that the perception of burden of Korean women family caregivers is strongly associated with the caregiving impact on their lives. We added the concept of caregiver’s beliefs to the conceptual framework based on Poulshock and Deimling caregiving burden model, because caregivers’ beliefs that are deeply rooted in cultural values may influence caregiving impact including caregiver’s behavior, resulting from caregiver’s feelings (J. Kim, Knight, & Flynn Longmire, 2007). Liese and Beck (1997) described that beliefs are the core component of cognitive behavioral model based on the assumption that thoughts or beliefs influence emotional response and behavior. Janevic and Connell (2001) reported that culture influenced the experiences of family caregivers in terms of burden. Culture refers to commonly held values and beliefs (Aranda & Knight, 1997) such as caregivers’ beliefs about their caregiving role. One of caregiver’s beliefs and values is


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Antecedents

Perception

Consequences

Disruptive Behavior Burden Negative Changes in Family Relationships

Elder’s Impairment in Activities of Daily Living

Elder’s Cognitive impairment

Caregiver’s Self-Efficacy

Social Activity Restriction

Caregiver’s Familism Social Functioning Burden

Figure 1. Staged theoretical model.

familism, which is a significant predictor of burden and caregiving impact in women family caregivers’ lives (Cheng, Lam, Kwok, Ng, & Fung, 2012; Lim, Ko, Kim, & Park, 2008). The other caregiver’s belief is self-efficacy, which might be an indicator of caregiving burden (Campbell et al., 2008). Some research studies reported that low perceived self-efficacy may affect burden experienced by family caregivers (Campbell et al., 2008; Gallagher et al., 2011; Uei, Sung, & Yang, 2013). Although identifying predictors of caregiving burden among women family caregivers has received considerable attention, few nursing studies have systematically considered cultural knowledge-based explanations for the relationships affecting the multidimensional caregiving burden in Korean women family caregivers. Therefore, the purpose of this study was to test a staged theoretical model designed to explain the relationships affecting the multidimensional burden of female family caregivers caring for communitydwelling older Korean adults.

Conceptual Framework The modified Poulshock and Deimling model has been used to test theoretical assertions and empirical investigations in the caregiving burden literature (Campbell et al., 2008; Cheng et al., 2012; Dunkin & Anderson-Hanley, 1998; Gallagher et al., 2011; Lim et al., 2008; Torti, Gwyther, Reed, Friedman, & Schulman, 2004). In Figure 1, the modified model shows three stages, antecedent (Stage 1), perception (Stage 2), and consequence (Stage 3). Stage


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1 contains two subcategories: elders’ impairments and caregiver beliefs. Elders’ impairments include impairment in ADL and cognitive impairment. Impairment in ADL refers to physical dependence on basic ADL such as transfers and bathing (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963). Cognitive impairment refers to cognitive decline such as forgetfulness, memory loss, and repetition of words (Moyer, 2014). Caregiver beliefs include two subcategories: familism and self-efficacy. Familism is a cultural value that refers to solidarity of individuals with their family as well as strong normative feelings of allegiance, dedication, reciprocity, and attachment to their family members (Losada et al., 2006). Familism in Korea is based on Confucian values and continues to reflect traditional values with an emphasis on filial piety (Ahn, Youn, Phillips, & Lim, 2011). Ramos (2004) proposed that the cultural value of familism is at the root of family caregiving, and Youn, Knight, Jeong, and Benton (1999) showed that strong familism value had an influence on the high level of burden experienced by Korean family caregivers. Self-efficacy is defined as one’s belief in one’s ability to achieve, and refers to the amount of confidence held that one can achieve specific behaviors or tasks (Bandura, 1991). Self-efficacy often affects how well family caregivers deal with caregiving for older adults (Campbell et al., 2008; Cheng et al., 2012; Gallagher et al., 2011). In Stage 2, the perception variable is burden, which includes disruptive behavior burden and social functioning burden. Poulshock and Deimling’s disruptive behavior burden and social functioning burden refer to caregiver’s feelings of oppression, discomfort, and distress arising both from the elder’s disruptive behavior (i.e., yelling or swearing at people) and from the elder’s difficulties with social functioning (i.e., not being friendly or sociable toward people; Poulshock & Deimling, 1984). Several studies have indicated that caregiver’s feelings of distress arising from elder’s behaviors result from the extent of physical and cognitive impairment of older adult (Cho et al., 2010; Lim et al., 2008; Papastavrou et al., 2007; Poulshock & Deimling, 1984; Zhang et al., 2013). In Stage 3, the consequence variable is impact on burden, which includes negative changes in family relationships and social activity restriction. Negative changes in family relationships refer to the impact of caregiving on the caregiver’s interpersonal relationships with the elder (i.e., angry, depressed, resentful, strained; Poulshock & Deimling, 1984). Social activity restriction is explained as the effect of caregiving on the caregiver’s personal and social life, including decreased social activities and role strain (Poulshock & Deimling, 1984). In the theoretical staged model, a direct relationship was anticipated between caregiver’s feelings of distress and negative impact, and


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it was expected that elder’s impairments and low level of caregiver’s beliefs had an indirect influence on negative impact through caregiver’s feelings of distress. Research Question 1: What is the magnitude and direction of the relationships between the dependent variables (social activity restriction, negative changes in family relationships), two endogenous variables (disruptive behavior burden, social functioning burden), and four exogenous variables (elder’s cognitive impairment, elder’s impairment in ADL, caregiver’s familism, caregiver’s self-efficacy)?

Method Design and Participants In this study, a cross-sectional descriptive research design was used to test a staged theoretical model designed to explain factors affecting the impact of the family caregiver burden. Data were collected with a convenience sample of female family caregivers caring for community-dwelling frail older adults who have a chronic disease with the need for help in ADL. The inclusion criteria for community-residing older adults were as follows: (a) 65 years and older; (b) having a medical diagnosis of hypertension, diabetes, arthritis, or stroke for longer than 6 months; and (c) needing to receive assistance at least one activity of daily living. The inclusion criteria for caregivers were as follows: (a) a relative (older than 18 years); (b) serving as a primary female caregiver and having an intimate knowledge of the elder over time; and (c) agreeing to be interviewed. A total of 157 primary female caregivers participated. Sample size was calculated using power analysis with the G*Power 3.1 program. A sample size of 123 subjects was calculated to have a 0.90 efficacy in detecting small to medium effect size with six predictors at the 5% level of significance in multiple regression analysis, indicating that the number of participants in this study was sufficient.

Instruments General Self-Efficacy Scale (GSES). Self-efficacy was measured by the Korean version of the General Self-Efficacy Scale (GSES-K; Suh, 1995) to determine caregiver’s belief in caregiver’s ability to care older adults. The GSESK was supported in psychometric testing in a previous study by Suh (1995), in which the internal consistency coefficient of alpha was .71. The GSES-K


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is composed of 17 items on a 5-point Likert-type scale. A summated score of the 17 items is calculated, with higher scores indicating high belief in the ability to do things for oneself. In this study, internal consistency for the GSES-K was 0.83. Family Scale. Familism was measured by the Family Scale–Korean version (FS-K; Ahn et al., 2011). The FS-K has 21 items and is composed of the major components of filial obligation (e.g., “Children should be willing to take care of their parents in whatever way necessary when they are sick”), proximity (e.g., “Married children should live close to their parents”), kin orientation (e.g., “When you get right down to it, nobody but your family really cares about you”), affectionate solidarity (e.g., “Even when children have families of their own, they should keep in close contact with their parents”), instrumental solidarity (e.g., “Holidays are good only if they are shared with family”), and self-sacrifice (e.g., “Getting a better job can be a bad thing if it keeps you from being close to family”). It is measured on a 4-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree). The FS-K yields a summated score, ranging from 21 to 88, with a high score indicating high familistic attitudes. In this study, internal consistency for the FS-K was 0.84. Burden Scale. Multidimensional burden was measured by the Poulshock and Deimling’s (1984) Burden Scale, which consists of three subcategories including six subscales designed to measure multidimensional concepts of burden. Three bilingual nursing scholars translated each item into Korean. After another bilingual scholar performed a blind back-translation, a native speaker compared it with the original English version. The semantic meaning was clarified by refining and revising the wording of each item of the Korean version of Burden Scale, which was written at a fifth-grade reading level. The Burden Scale has three subcategories: impairment, burden, and impact. Elder impairment subcategory is comprised of two subscales: Impairment in Activities of Daily Living subscale and Cognitive Impairment subscale. Impairment in Activities of Daily Living subscale contains six items (e.g., bathing, dressing, toileting, etc.) on a 5-point Likert-type scale (1 = completely independent to 5 = completely dependent). A summated score of the six items was calculated, with high scores indicating high physical problems associated with ADL. Cognitive Impairment subscale contained five items (e.g., forgetfulness, telling the same thing over and over) on a 3-point Likert-type scale (1 = never, 2 = sometimes, 3 = always). A summated score of the five items was calculated, with high scores indicating high cognitive problems of older persons such as forgetfulness.


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Burden category contained two subscales: Disruptive Behavior Burden subscale and Social Functioning Burden subscale. The Disruptive Behavior Burden subscale consisted of seven items (e.g., “Your elder complaining about things”) and the Social Functioning Burden subscale consisted of four items (e.g., “Your elder not interesting to talk with”) on 4-point Likert-type scale (1 = no upset, 2 = a little upset, 3 = somewhat upset, 4 = very upset) and calculated as a sum of item scores in each subscale, with high scores indicating high caregiver emotional distress for the caregiving burden. Impact category consisted of two subscales including 15 items designed to measure the extent to which specific aspects of family life were altered as a result of caregiving for a frail older adult. The impact subcategory contained two subscales: Negative Changes in Family Relationships subscale and Social Activity Restrictions subscale. The Negative Changes in Family Relationships subscale contained 8 items (e.g., “I feel angry toward my elder”) on a 3-point Likert-type scale (1 = disagree, 2 = average, 3 = agree), with high scores indicating high negative feelings related to caregiving. The Social Activity Restrictions subscale contained 7 items (e.g., “Since I’ve been caring for my elder, I visit with friends or family less”) with binominal items (0 = no, 1 = yes). A summated score of the 7 items was calculated, with higher scores indicating higher limitations of activities and lack of time for self. In this study, Cronbach’s alphas for each subscale on the Poulshock and Deimling’s (1984) Burden Scale ranged from .79 to .92.

Data Collection The directors of outpatient clinics of orthopedics, neurosurgery, and internal medicine in a suburban general hospital in Korea were contacted by research teams. The outpatient clinics were chosen because family caregivers accompanied frail older adults who visited the doctor. Before data collection, three senior nursing students were trained as research assistants to use open-ended questions to complete the instruments. After approval from the directors of each clinic was obtained, three trained research assistants asked potential female caregivers who visited with elder patients for permission to describe the study to them. Potential participants were given an explanation of the study, and informed that filling out the questionnaire posed no harm, risk, or mental/physical discomfort. In addition, potential participants were informed that they had the right to withdraw from filling out the questionnaire at any time. Once informed consent was obtained, the participants were given the option of completing the instruments independently or with assistance using interview by research assistants in the waiting room of the outpatient clinic. In this study, three women withdrew and therefore failed to complete the questionnaire.


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Data Analysis The research question was answered using path analysis. Data were analyzed using the multiple linear regression method to examine the model. The model variables were entered into the equation according to stage and their bivariate relationship to the dependent variable. Beta weights at the statistically significant level of .05 were included in the analysis.

Results As shown in Table 1, ages of the women family caregivers ranged from 19 to 80 years, with a mean of 47.1 years (standard deviation [SD] = 9.39). Most caregivers were married (n = 148, 94.3%) and had an education beyond high school (n = 127, 80.9%). Almost two thirds of the caregivers (n = 107, 68.2%) reported religious affiliation and 87% (n = 136) of caregivers reported perceiving their family economic status as average, while 2.6% reported a high family economic status, and 10.8% reported a low family economic status. Approximately 60% (n = 94) of family caregivers lived with the elderly family member, and 59.2% of caregivers (n = 93) were daughters-in-law. Figure 2 shows the empirical results in the staged theoretical model of caregiving burden among women family caregivers. The path diagram illustrates the relationships among different variables. Path coefficients indicate the direction and magnitude of the direct effects among the variables. Values along the arrows are direct-effect coefficients. For the dependent variable, negative changes in family relationships were tested: Negative Changes in Family Relationships = (constant) + Disruptive Behavior Burden + Social Functioning Burden + Impairment in Activities of Daily Living + Cognitive Impairment + Familism + Self-Efficacy. In the final model (Figure 2), Negative Changes in Family Relationships = 5.855 + 0.58 Disruptive behavior burden. The independent variables explain 64% of the variability of negative changes in family relationships. Only disruptive behavior burden (β = .58, p = .000) statistically significantly predicted negative changes in family relationships, indicating that the greater the disruptive behavior burden, the more the caregivers perceived negative changes in family relationships. The other three exogenous variables made no significant contribution to the explained variance because of the weak association between the other elder impairment-caregiver factors and caregiving impact. For the other dependent variable, social activity restriction, the following equation was tested: Social Activity Restriction = (constant) + Disruptive Behavior Burden + Social Functioning Burden + Impairment in Activities of Daily Living + Cognitive Impairment + Familism + Self-Efficacy. In the final


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Table 1. Sociodemographic Characteristics of Subjects. Variable Age Marital status Education Religion Perception of family economic status Living arrangement with older adults Relationship with older adult

Category

n (%)

M ± SD (range)

Married Single Separated No education Elementary Middle school High school College Protestant Catholic Buddhism Others None Very high

148 (94.3) 7 (4.5) 2 (1.3) 2 (1.3) 7 (4.5) 21 (13.4) 91 (58.0) 36 (22.9) 70 (44.6) 10 (6.4) 25 (15.9) 2 (1.3) 50 (31.8) 2 (1.3)

47.1 + 9.39 (19-80)

High Average Low Very low Yes

2 (1.3) 136 (86.6) 12 (7.6) 5 (3.2) 94 (59.9)

63 (40.1) 53 (33.8)

93 (59.2) 11 (7.0)

No Children/ grandchildren Daughter-in-law Spouse

model, Social Activity Restriction = 7.484 + 0.30 Social Functioning Burden + 0.49 Impairment in Activities of Daily Living − 0.17 Self-Efficacy. Fortyone percent of total variance in the social activity restriction was explained by the six independent variables, and social functioning burden (β = .30, p = .000), physical dependency (β = .49, p = .000), and self-efficacy (β = −.17, p = .013) had a direct effect on social activity restriction. This indicates that caregivers who care for elders with high impairment in ADL, and have perceived low self-efficacy and high burden due to poor social functioning of elders, were more likely to have greater social activity restriction.


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Lim et al. Antecedents

Perception

Disruptive Behavior Burden R2=30.6

Elder’s Impairment in Activities of Daily Living

Consequences

Β=.580

Negative Changes in Family Relationships R2=64.2

Β=.256

Β=-.310

Elder’s Cognitive Impairment Β= -.280 Β= -.282

Caregiver’s Self-Efficacy

Β= -.321

Caregiver’s Familism

Social Activity Restriction

Β= -.172

R2=43.5

Β=.364

Β= .260 Β=.302 Β=.182

Social Functioning Burden R2=42.9

Figure 2. β, Staged theoretical model with empirical results.

For disruptive behavior burden, the following equation was tested: Disruptive Behavior Burden = (constant) + Impairment in Activities of Daily Living + Cognitive Impairment + Self-Efficacy + Familism. In the final model testing, Disruptive Behavior Burden = 24.35 − 0.31 Cognitive Impairment + 0.26 Familism − 0.28 Self-Efficacy. In Figure 2, four independent variables explained 30.6% of the total variance in the disruptive behavior burden, and cognitive impairment (β = −.31, p = .000), familism (β = .26, p = .000), and self-efficacy (β = −.28, p = .000) had a statistically significant influence on the disruptive behavior burden. These relationships indicate that the higher the cognitive impairment of the older adult, the greater the likelihood that women caregivers perceived the disruptive behavior of older adults as a burden. The results also showed that female caregivers who had strong familism and low self-efficacy perceived the disruptive behavior of older adults as more of a burden than those with weak familism and high selfefficacy. The other personal factors in Stage 1 (i.e., impairment in ADL) made no significant contribution to the explained variance. The impairment variable (cognitive impairment) of the older adult and caregiver factors (i.e., familism and self-efficacy) had indirect effects on negative changes in family relationships through the disruptive behavior burden. For the other perception variable, social functioning burden, the following equation was tested: Social Functioning Burden = (constant) + Impairment in Activities of Daily Living + Cognitive Impairment + Self-Efficacy + Familism. In the final model testing, Social Functioning Burden = 17.53 − 0.28 Cognitive Impairment + 0.36 Impairment in Activities of Daily Living +


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0.18 Familism − 0.32 Self-Efficacy. All independent variables explained 42.9% of the total variance in the social functioning burden, and cognitive impairment (β = −.28, p = .000), impairment in ADL (β = .36, p = .000), familism (β = .18, p = .000), and self-efficacy (β = −.32, p = .000) statistically significantly predicted social functioning burden. These relationships indicate that the higher the cognitive impairments of the older adult, the greater the likelihood that female caregivers perceived the social functioning of older adults as a burden. The results also showed that female caregivers who had strong familism and low self-efficacy perceived the disruptive behavior of older adults as more of a burden than those with weak familism and high selfefficacy. Elders’ impairment factors and caregiver factors had indirect effects on negative changes in family relationships through the social functioning burden.

Discussion In the present study, a staged theoretical model was posited to explain the multidimensional burden of Korean women family caregivers. This study presents several interesting findings. First, in this study, self-efficacy had an indirect influence on caregiving impact through burden perception, indicating that women family caregivers with low confidence in caring for older adults experienced feelings of distress and embarrassment due to the behavior of older adults, resulting in negative outcomes, including adverse changes in family relationships and social activity restriction. Furthermore, selfefficacy had a direct effect on caregiving impact, indicating that family caregivers with lower self-efficacy had restricted social life. These results are consistent with findings in several previous studies across cultures (Cheng et al., 2012; Hagedoorn, Sanderman, Buunk, & Wobbes, 2002; Keefe et al., 2003; Romero-Moreno et al., 2011). The findings have implications for understanding of self-efficacy as personal belief and value which might be a critical factor in changes in emotional response and impact behavior. Research on perceived burden resulting from self-efficacy needs to be further considered, and intervention for family caregivers to improve self-efficacy for caregiving needs to be further developed. Second, with regard to familism, the finding displayed that familism had an indirect effect on caregiving impact through burden perception. The present study expectedly showed that the stronger the familistic values and beliefs of family caregivers, the greater emotional distress they perceived, resulting in negative changes in family relationships and social activity restriction. This outcome is inconsistent with findings in other cultures (Losada et al., 2006; Shurgot & Knight, 2004), where familism was significantly correlated


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with lesser burden in the Latino caregiver community. One possible explanation for the findings in this study is that Korean familism is very deeply rooted in filial piety, which is strongly influenced by Confucianism (H. Y. Kim, 2004). Filial piety generates strong filial responsibility and obligations for children and family members to care for parents (Ahn et al., 2011; Sung & Kim, 2003). In this type of society, there is still a pronounced sense of family obligation, especially for women (J. S. Kim, 2001; J. S. Kim & Lee, 2003; Knight et al., 2002; E. E. Lee & Farran, 2004). Women in the traditional Korean family system might naturally expect to care for elderly family members if they become sick (J. S. Kim & Lee, 2003). Paradoxically, even though women have a great sense of filial obligation, they may feel stress when caring for frail older adults because the expectations for the caring role are so high. These results suggest that emotional response associated with embarrassment and overload may be significant components resulting in negative caregiving impacts, and can result in negative changes in family relationships and social activity restrictions for women family caregivers who have strong familism. The results in this study have significant implications for understanding of familism rooted in cultural belief or value which might be also a crucial factor in changes in emotional response and impact behavior of family caregivers. These findings suggest the need to educate community health or geriatric nurses in community settings. Cross-cultural research on the relationship between cultural-based familism and impact behaviors of women family caregivers needs to be further considered. Third, in addition to caregiver belief factors in this study, elders’ impairments (i.e., impairment in ADL, cognitive impairment) had an indirect influence on caregiving impact due to perceived burden. The findings indicated that family caregivers caring for older adults with high impairments in ADL perceived feelings of embarrassment related to poor social functioning of older adults, which result in social activity restriction. The results also indicate that family caregivers caring for older adults with high cognitive impairment perceived stress due to the disruptive behaviors of older adults, ultimately leading to negative changes in family relationships. Although not directly associated with caregiving impact, cognitive impairments in older adults impact the perceived burden and indirectly influence negative changes in family relationships. This is consistent with findings from other studies across cultures (Cho et al., 2010; M. H. Lee et al., 2007; Perren, Schmid, & Wettstein, 2006; Poulshock & Deimling, 1984; Zhang et al., 2013), in which the outcomes of negative changes in family relationships and social activity restriction were influenced by the types of impairments affecting the older adults. Fourth, when comparing the strength of the relationship among antecedent variables, burden, and caregiving consequence, striking differences were


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apparent. Among the independent variables, disruptive behavior burden had the greatest influence on negative changes in family relationships. This result indicates that caregiver distress or feelings of embarrassment due to the disruptive behavior of older adults is strongly associated with negative changes in family relationships. This is consistent with other studies across cultures (Chun, Knight, & Youn, 2007; Heru, Ryan, & Iqbal, 2004; Poulshock & Deimling, 1984; Spitznagel, Tremont, Davis, & Foster, 2006), in which negative changes in family relationships were influenced more by the perceived distress arising from the disruptive behaviors of older adults than by other factors. The findings in this study have implications for nursing practices designed to help women family caregivers reduce negative caregiving impact. This study showed that both impairments of older adults and caregiver beliefs (i.e., strong familism, low self-efficacy) had a negative influence on caregiving impact through the perceived emotional distress. The relationships among caregiving outcomes can guide researchers and community health and geriatric nurses in understanding self-efficacy and familism rooted in cultural value. Such knowledge will enable an understanding of the negative emotional response of women family caregivers and the development of more sensitive caregiver interventions to reduce both negative changes in family relationships and social activity restrictions. The respondents were not representative of all Korean women family caregivers, and therefore generalization of the results is not possible. Replication of the present study with a larger sample size is needed to further enrich knowledge regarding cultural knowledge-based factors affecting the multidimensional caregiving burden in Korean women family caregivers of community-dwelling older adults. Whether caregiving outcome is culturally relevant to other ethnic groups has not yet been identified. Cross-cultural differences or similarities in the theoretical model explaining the impairments of older adults and caregiver beliefs that affect impact behavior through negative emotional responses also need to be examined. The findings of the present study suggest that further refinement of the underlying model is warranted. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.


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Author Biographies Young Mi Lim is a professor at the Department of Nursing, Wonju College of Medicine, Yonsei University, Korea. Yang Heui Ahn is a professor at the Department of Nursing, Wonju College of Medicine, Yonsei University, Korea. Ji Yeong Ahn is a teaching assistant at the Department of Nursing, Wonju College of Medicine, Yonsei University, Korea.


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